Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if: You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract; You were enrolled in another B...
